Preparing Patient

Preparing patientPreparing patient

ByBy

Arif MuttaqinArif Muttaqin

Preparation Preparation

Pleural biopsyPleural biopsy

Bronchoscopy Bronchoscopy

Peritoneal paracentesisPeritoneal paracentesis

Liver biopsyLiver biopsy

Lumbar punctureLumbar puncture


Preparation of:Preparation of:– NurseNurse– Patient Patient – RoomRoom– EquipmentEquipment


Preparation of Nurse :Preparation of Nurse :– Knowledge Knowledge

Anatomy and physiologyAnatomy and physiologyProcedural institutionsProcedural institutions

– Skill : Skill : Cognitive Cognitive InterpersonalInterpersonalPsychomotor Psychomotor

– Attitude Attitude Professional Professional


Preparation of Patient :Preparation of Patient :– Assessment: Assessment:

Orders,Orders,

Cooperative levels.Cooperative levels.

Diagnostics.Diagnostics.

– Informed consentInformed consent– Privacy Privacy – Physical Physical – Position Position

PreparationPreparation

Preparation of Room :Preparation of Room :– Operation tableOperation table– Temperature Temperature

– NoiseNoise


Preparation of Preparation of EquipmentEquipment::– Technical procedure Technical procedure – Procedural institutions Procedural institutions – Patient Patient

Pleural biopsy PreparationPleural biopsy Preparation


Definition:Definition:– The pleura is the membrane that lines The pleura is the membrane that lines

the lungs and chest cavity. A pleural the lungs and chest cavity. A pleural biopsybiopsy is the removal of pleural tissue is the removal of pleural tissue for examination and eventual diagnosis for examination and eventual diagnosis

Alternative Names:Alternative Names:Closed pleural biopsy; Needle biopsy of the Closed pleural biopsy; Needle biopsy of the

pleura pleura

PurposePurpose Pleural biopsy Pleural biopsy

Pleural biopsy is performed to differentiate Pleural biopsy is performed to differentiate between benign (noncancerous) and between benign (noncancerous) and malignant (cancerous) disease, to malignant (cancerous) disease, to diagnose viral, fungal, or diagnose viral, fungal, or parasitic diseases, and to identify a , and to identify a condition called collagen vascular disease condition called collagen vascular disease of the pleura. of the pleura. It is also ordered when a chest It is also ordered when a chest x rayx ray indicates a pleural-based indicates a pleural-based tumor, reaction, , reaction, or pleural thicknessor pleural thickness


Preparations for this procedure vary, Preparations for this procedure vary, depending on the type of procedure depending on the type of procedure requested. requested. – Closed Closed needle biopsy requires little or no requires little or no

preparation. preparation. – Open pleural biopsy, which is performed in a , which is performed in a

hospital, requires fasting (no solids or liquids) hospital, requires fasting (no solids or liquids) for 8-12 hours before the procedure because for 8-12 hours before the procedure because the stomach must be empty before the stomach must be empty before general anesthesia is administered. is administered.

ThoracentesisThoracentesis

DefinitionDefinition– A A pleural biopsy is a procedure to remove a sample of the tissue is a procedure to remove a sample of the tissue

lining the lungs and the inside of the chest wall to check for lining the lungs and the inside of the chest wall to check for disease or infection.disease or infection.

Alternative NamesAlternative Names– Closed pleural biopsy; Needle biopsy of the pleuraClosed pleural biopsy; Needle biopsy of the pleura

How the test is performedHow the test is performed– This test does not have to be done in the hospital. It may be This test does not have to be done in the hospital. It may be

done at a clinic or doctor's office.done at a clinic or doctor's office.– Patient will be sitting up for the biopsy. The health care provider Patient will be sitting up for the biopsy. The health care provider

will cleanse the skin at the biopsy site, and inject a local will cleanse the skin at the biopsy site, and inject a local numbing drug (anesthetic) through the skin and into the lining of numbing drug (anesthetic) through the skin and into the lining of the lungs and chest wall (pleural membrane).the lungs and chest wall (pleural membrane).

Thoracentesis Preparation Thoracentesis Preparation

Thoracentesis (also referred to as Pleural Thoracentesis (also referred to as Pleural fluid aspiration or Pleural tap) is a fluid aspiration or Pleural tap) is a procedure to remove fluid from the space procedure to remove fluid from the space between the lining of the outside of the between the lining of the outside of the lungs (pleura) and the wall of the chest. lungs (pleura) and the wall of the chest. Normally, very little fluid is present in this Normally, very little fluid is present in this space. An accumulation of excess fluid space. An accumulation of excess fluid between the layers of the pleura is called a between the layers of the pleura is called a pleural effusion. pleural effusion.

THE THORACENTESIS THE THORACENTESIS PROCEDUREPROCEDURE

A small area of skin on Patientr chest or back is A small area of skin on Patientr chest or back is washed with a sterilizing solution. Some washed with a sterilizing solution. Some numbing medicine (local anesthetic) is injected numbing medicine (local anesthetic) is injected in this area. in this area.

A needle is then placed through the skin of the A needle is then placed through the skin of the chest wall into the space around the lungs called chest wall into the space around the lungs called the pleural space. Fluid is withdrawn and the pleural space. Fluid is withdrawn and collected and may be sent to a laboratory for collected and may be sent to a laboratory for analysis (pleural fluid analysis). analysis (pleural fluid analysis).

In a pleural biopsy, a small piece of pleural tissue in the chest is removed with a needle. The biopsy may distinguish between a cancerous and noncancerous disease. It also can help to detect whether a viral, fungal or parasitic disease is present.

PREPARING FOR THE PREPARING FOR THE PROCEDUREPROCEDURE

No special preparation is needed before No special preparation is needed before the procedure. A chest x-ray is may be the procedure. A chest x-ray is may be performed before and after the test. performed before and after the test.

Do not cough, breathe deeply, or move Do not cough, breathe deeply, or move during the test to avoid injury to the lung. during the test to avoid injury to the lung.

DURING THE PROCEDUREDURING THE PROCEDURE

Patient will sit on the edge of a chair or bed with Patient will sit on the edge of a chair or bed with Patient head and arms resting on a table. The Patient head and arms resting on a table. The skin around the procedure site is disinfected and skin around the procedure site is disinfected and the area is draped. A local anesthetic is injected the area is draped. A local anesthetic is injected into the skin. The thoracentesis needle is into the skin. The thoracentesis needle is inserted above the rib into the pleural space. inserted above the rib into the pleural space. There will be a stinging sensation when the local There will be a stinging sensation when the local anesthetic is injected, and Patient may feel a anesthetic is injected, and Patient may feel a sensation of pressure when the needle is sensation of pressure when the needle is inserted into the pleural space. inserted into the pleural space. Assess develop shortness of breath or chest Assess develop shortness of breath or chest pain. pain.

POTENTIAL RISKSPOTENTIAL RISKS

• • Pneumothorax (collapse of the lung) Pneumothorax (collapse of the lung)

• • Fluid re-accumulation Fluid re-accumulation

• • Pulmonary edema Pulmonary edema

• • Bleeding Bleeding

• • Infection Infection

• • Respiratory distress Respiratory distress

open pleural biopsy open pleural biopsy

DefinitionDefinition– An open pleural biopsy is a procedure to An open pleural biopsy is a procedure to

remove and examine the tissue that lines the remove and examine the tissue that lines the inside of the chest. This tissue is called the inside of the chest. This tissue is called the pleura.pleura.

Alternative NamesAlternative Names– Biopsy - open pleuraBiopsy - open pleura

In an open pleural biopsy, a small piece of the pleural tissue is removed through a surgical incision in the chest. After the sample is obtained, a chest tube is placed and the incision is closed with stitches. Abnormal results may indicate tuberculosis, abnormal growths, viral, fungal, and parasitic diseases.

Bronchoscopy PreparationBronchoscopy Preparation

RSUD Soetomo, 1994

BronchoscopyBronchoscopy

Definition Definition – Bronchoscopy is a procedure in which a Bronchoscopy is a procedure in which a

hollow, flexible tube called a bronchoscope is hollow, flexible tube called a bronchoscope is inserted into the airways through the nose or inserted into the airways through the nose or mouth to provide a view of the mouth to provide a view of the tracheobronchial tree. It can also be used to tracheobronchial tree. It can also be used to collect bronchial and/or lung secretions and to collect bronchial and/or lung secretions and to perform tissue biopsy. perform tissue biopsy.


PurposePurpose– During a bronchoscopy, the physician can During a bronchoscopy, the physician can

visually examine the lower airways, including visually examine the lower airways, including the larynx, trachea, bronchi, and bronchioles. the larynx, trachea, bronchi, and bronchioles. The procedure is used to examine the The procedure is used to examine the mucosal surface of the airways for mucosal surface of the airways for abnormalities that might be associated with a abnormalities that might be associated with a variety of lung diseases. Its use may be variety of lung diseases. Its use may be diagnostic or therapeutic. diagnostic or therapeutic.


Bronchoscopy may be used to examine and help diagnose: Bronchoscopy may be used to examine and help diagnose: – diseases of the lung, such as cancer or tuberculosis diseases of the lung, such as cancer or tuberculosis – congenital deformity of the lungs congenital deformity of the lungs – suspected tumor, obstruction, secretion, bleeding, or foreign body in the suspected tumor, obstruction, secretion, bleeding, or foreign body in the

airways airways – airway abnormalities, such as tracheal stenoses airway abnormalities, such as tracheal stenoses – persistent cough, or hemoptysis, that includes blood in the sputum persistent cough, or hemoptysis, that includes blood in the sputum

Bronchoscopy may also be used for the following therapeutic Bronchoscopy may also be used for the following therapeutic purposes: purposes: – to remove a foreign body in the lungs to remove a foreign body in the lungs – to remove excessive secretions to remove excessive secretions

Bronchoscopy can also be used to collect the following biopsy Bronchoscopy can also be used to collect the following biopsy specimens: specimens: – sputum sputum – tissue samples from the bronchi or bronchioles tissue samples from the bronchi or bronchioles – cells collected from washing the lining of the bronchi or bronchioles cells collected from washing the lining of the bronchi or bronchioles


If the purpose of the bronchoscopy is to take If the purpose of the bronchoscopy is to take tissue samples or biopsy, a forceps or tissue samples or biopsy, a forceps or bronchial brush are used to obtain cells. bronchial brush are used to obtain cells.

Alternatively, if the purpose is to identify an Alternatively, if the purpose is to identify an infectious agent, a bronchoalveolar lavage infectious agent, a bronchoalveolar lavage can be performed to gather fluid for culture can be performed to gather fluid for culture purposes. If any foreign matter is found in purposes. If any foreign matter is found in the airways, it can be removed as well. the airways, it can be removed as well.


The instrument used in bronchoscopy, a bronchoscope, is a The instrument used in bronchoscopy, a bronchoscope, is a slender, flexible tube less than 0.5 in (2.5 cm) wide and slender, flexible tube less than 0.5 in (2.5 cm) wide and approximately 2 ft (0.3 m) long that uses fiberoptic technology (very approximately 2 ft (0.3 m) long that uses fiberoptic technology (very fine filaments that can bend and carry light). There are two types of fine filaments that can bend and carry light). There are two types of bronchoscopes, a standard tube that is more rigid and a fiberoptic bronchoscopes, a standard tube that is more rigid and a fiberoptic tube that is more flexible. tube that is more flexible. The rigid instrument does not bend, does not see as far down into The rigid instrument does not bend, does not see as far down into the lungs as the flexible one, and may carry a greater risk of causing the lungs as the flexible one, and may carry a greater risk of causing injury to nearby structures. Because it can cause more discomfort injury to nearby structures. Because it can cause more discomfort than the flexible bronchoscope, it usually requires general than the flexible bronchoscope, it usually requires general anesthesia. However, it is useful for taking large samples of tissue anesthesia. However, it is useful for taking large samples of tissue and for removing foreign bodies from the airways. and for removing foreign bodies from the airways. During the procedure, the airway is never blocked since oxygen can During the procedure, the airway is never blocked since oxygen can be supplied through the bronchoscope. be supplied through the bronchoscope.

Bronchoscopy fiberopticsBronchoscopy fiberoptics

Bronchoscopy is usually performed in an endoscopy room, but may Bronchoscopy is usually performed in an endoscopy room, but may also be performed at the bedside. The patient is placed on his back also be performed at the bedside. The patient is placed on his back or sits upright. A pulmonologist, a specialist trained to perform the or sits upright. A pulmonologist, a specialist trained to perform the procedure, sprays an anesthetic into the patient's mouth or throat. procedure, sprays an anesthetic into the patient's mouth or throat. When anesthesia has taken effect and the area is numb, the When anesthesia has taken effect and the area is numb, the bronchoscope is inserted into the patient's mouth and passed into bronchoscope is inserted into the patient's mouth and passed into the throat. If the bronchoscope is passed through the nose, an the throat. If the bronchoscope is passed through the nose, an anesthetic jelly is inserted into one nostril. While the bronchoscope anesthetic jelly is inserted into one nostril. While the bronchoscope is moving down the throat, additional anesthetic is put into the is moving down the throat, additional anesthetic is put into the bronchoscope to anesthetize the lower airways. bronchoscope to anesthetize the lower airways. The physician observes the trachea, bronchi, and the mucosal lining The physician observes the trachea, bronchi, and the mucosal lining of these passageways looking for any abnormalities that may be of these passageways looking for any abnormalities that may be present. If samples are needed, a bronchial lavage may be present. If samples are needed, a bronchial lavage may be performed, meaning that a saline solution is introduced to flush the performed, meaning that a saline solution is introduced to flush the area prior to collecting cells for laboratory analysis. Very small area prior to collecting cells for laboratory analysis. Very small brushes, needles, or forceps may also be introduced through the brushes, needles, or forceps may also be introduced through the bronchoscope to collect tissue samples from the lungs. bronchoscope to collect tissue samples from the lungs.

Bronchoscopy can be performed via the patient's mouth (A) or through the nose (C). During the procedure, the scope is fed down the trachea and into the bronchus leading to the lungs (B), providing the physician with a view of internal structures (D).


The patient should fast for six to 12 hours prior to the procedure and The patient should fast for six to 12 hours prior to the procedure and refrain from drinking any liquids the day of the procedure. refrain from drinking any liquids the day of the procedure. Smoking should be avoided for 24 hours prior to the procedure and Smoking should be avoided for 24 hours prior to the procedure and patients should also avoid taking any patients should also avoid taking any aspirin or ibuprofen-type or ibuprofen-type medications. medications. The bronchoscopy itself takes about 45–60 minutes. Prior to the The bronchoscopy itself takes about 45–60 minutes. Prior to the bronchoscopy, several tests are usually done, including a chest x bronchoscopy, several tests are usually done, including a chest x ray and blood work. ray and blood work. Sometimes a bronchoscopy is done under general anesthesia, in Sometimes a bronchoscopy is done under general anesthesia, in which case the patient will have an intravenous (IV) line in the arm. which case the patient will have an intravenous (IV) line in the arm. More commonly, the procedure is performed under local anesthesia, More commonly, the procedure is performed under local anesthesia, which is sprayed into the nose or mouth. This is necessary to inhibit which is sprayed into the nose or mouth. This is necessary to inhibit the gag reflex. A sedative also may be given. A signed consent form the gag reflex. A sedative also may be given. A signed consent form is necessary for this procedure. is necessary for this procedure.


PurposePurpose– During a bronchoscopy, the physician can During a bronchoscopy, the physician can

visually examine the lower airways, including visually examine the lower airways, including the larynx, trachea, bronchi, and bronchioles. the larynx, trachea, bronchi, and bronchioles. The procedure is used to examine the The procedure is used to examine the mucosal surface of the airways for mucosal surface of the airways for abnormalities that might be associated with a abnormalities that might be associated with a variety of lung diseases. Its use may be variety of lung diseases. Its use may be diagnostic or therapeutic. diagnostic or therapeutic.

Aftercare BronchoscopyAftercare Bronchoscopy

After the bronchoscopy, the vital signs (heart rate, blood pressure, After the bronchoscopy, the vital signs (heart rate, blood pressure, and breathing) are monitored. Sometimes patients have an and breathing) are monitored. Sometimes patients have an abnormal reaction to anesthesia. Any sputum should be collected in abnormal reaction to anesthesia. Any sputum should be collected in an emesis basin so that it can be examined for the presence of an emesis basin so that it can be examined for the presence of blood. blood. If a biopsy was taken, the patient should not cough or clear the If a biopsy was taken, the patient should not cough or clear the throat as this might dislodge any blood clot that has formed and throat as this might dislodge any blood clot that has formed and cause bleeding. No food or drink should be consumed for about two cause bleeding. No food or drink should be consumed for about two hours after the procedure or until the anesthesia wears off. hours after the procedure or until the anesthesia wears off. There is a significant risk for choking if anything (including water) is There is a significant risk for choking if anything (including water) is ingested before the anesthetic wears off, and the gag reflex has ingested before the anesthetic wears off, and the gag reflex has returned. To test if the gag reflex has returned, a spoon is placed on returned. To test if the gag reflex has returned, a spoon is placed on the back of the tongue for a few seconds with light pressure. If there the back of the tongue for a few seconds with light pressure. If there is no gagging, the process is repeated after 15 minutes. is no gagging, the process is repeated after 15 minutes. The gag reflex should return in one to two hours. Ice chips or clear The gag reflex should return in one to two hours. Ice chips or clear liquids should be taken before the patient attempts to eat solid food. liquids should be taken before the patient attempts to eat solid food.

Aftercare Aftercare BronchoscopyBronchoscopy

Patients are informed that after the anesthetic Patients are informed that after the anesthetic wears off the throat may be irritated for several wears off the throat may be irritated for several days. days.

Patients should notify their health care provider Patients should notify their health care provider if they develop any of these symptoms: if they develop any of these symptoms: – hemoptysis (coughing up blood) hemoptysis (coughing up blood) – shortness of breath, wheezing, or any trouble shortness of breath, wheezing, or any trouble

breathing breathing – chest pain chest pain – fever, with or without breathing problems fever, with or without breathing problems

RisksRisks

Use of the bronchoscope mildly irritates the Use of the bronchoscope mildly irritates the lining of the airways, resulting in some swelling lining of the airways, resulting in some swelling and inflammation, as well as hoarseness caused and inflammation, as well as hoarseness caused from abrading the vocal cords. If this abrasion is from abrading the vocal cords. If this abrasion is more serious, it can lead to respiratory difficulty more serious, it can lead to respiratory difficulty or bleeding of the lining of the airways. or bleeding of the lining of the airways. The bronchoscopy procedure is also associated The bronchoscopy procedure is also associated with a small risk of disordered heart rhythm with a small risk of disordered heart rhythm (arrhythmia), heart attacks, low blood oxygen (arrhythmia), heart attacks, low blood oxygen (hypoxemia), and pneumothorax (a puncture of (hypoxemia), and pneumothorax (a puncture of the lungs that allows air to escape into the space the lungs that allows air to escape into the space between the lung and the chest wall). between the lung and the chest wall).

RisksRisks

These risks are greater with the use of a rigid bronchoscope than These risks are greater with the use of a rigid bronchoscope than with a fiberoptic bronchoscope. If a rigid tube is used, there is also a with a fiberoptic bronchoscope. If a rigid tube is used, there is also a risk of chipped teeth. The risk of transmitting infectious disease from risk of chipped teeth. The risk of transmitting infectious disease from one patient to another by the bronchoscope is also present. one patient to another by the bronchoscope is also present. There is also a risk of infection from endoscopes inadequately There is also a risk of infection from endoscopes inadequately reprocessed by the automated endoscope reprocessing (AER) reprocessed by the automated endoscope reprocessing (AER) system. The Centers for Disease Control (CDC) reported cases of system. The Centers for Disease Control (CDC) reported cases of patient-to-patient transmission of infections following bronchoscopic patient-to-patient transmission of infections following bronchoscopic procedures using bronchoscopes that were inadequately procedures using bronchoscopes that were inadequately reprocessed by AERs. reprocessed by AERs. Investigation of the incidents revealed inconsistencies between the Investigation of the incidents revealed inconsistencies between the reprocessing instructions provided by the manufacturer of the reprocessing instructions provided by the manufacturer of the bronchoscope and the manufacturer of the AER; or that the bronchoscope and the manufacturer of the AER; or that the bronchoscopes were inadequately reprocessed. bronchoscopes were inadequately reprocessed.

Normal resultsNormal results

If the results of the bronchoscopy are normal, the windpipe (trachea) If the results of the bronchoscopy are normal, the windpipe (trachea) appears as smooth muscle with C-shaped rings of cartilage at appears as smooth muscle with C-shaped rings of cartilage at regular intervals. There are no abnormalities either in the trachea or regular intervals. There are no abnormalities either in the trachea or in the bronchi of the lungs. in the bronchi of the lungs. Bronchoscopy results may also confirm a suspected diagnosis. This Bronchoscopy results may also confirm a suspected diagnosis. This may include swelling, ulceration, or deformity in the bronchial wall, may include swelling, ulceration, or deformity in the bronchial wall, such as inflammation, stenosis, or compression of the trachea, such as inflammation, stenosis, or compression of the trachea, neoplasm, and foreign bodies. The bronchoscopy may also reveal neoplasm, and foreign bodies. The bronchoscopy may also reveal the presence of atypical substances in the trachea and bronchi. If the presence of atypical substances in the trachea and bronchi. If samples are taken, the results could indicate cancer, disease-samples are taken, the results could indicate cancer, disease-causing agents, or other lung diseases. Other findings may include causing agents, or other lung diseases. Other findings may include constriction or narrowing (stenosis), compression, dilation of constriction or narrowing (stenosis), compression, dilation of vessels, or abnormal branching of the bronchi. Abnormal vessels, or abnormal branching of the bronchi. Abnormal substances that might be found in the airways include blood, substances that might be found in the airways include blood, secretions, or mucous plugs. secretions, or mucous plugs.

Peritoneal paracentesisPeritoneal paracentesis

IntroductionIntroduction

Paracentesis is a Paracentesis is a procedure in which procedure in which a needle or a needle or catheter is inserted catheter is inserted into the peritoneal into the peritoneal cavity to obtain cavity to obtain ascitic fluid for ascitic fluid for diagnostic or diagnostic or therapeutic therapeutic purposes purposes

IndicationsIndications

Diagnostic:Diagnostic:– New onset ascites:New onset ascites:

To determine aetiology. To determine aetiology. To differentiate transudate versus exudate. To differentiate transudate versus exudate. To detect cancerous cells. To detect cancerous cells.

– Suspected spontaneous or secondary bacterial Suspected spontaneous or secondary bacterial peritonitis peritonitis

Therapeutic:Therapeutic:– To relieve respiratory distress secondary to ascites. To relieve respiratory distress secondary to ascites. – To relieve abdominal pain or pressure secondary to To relieve abdominal pain or pressure secondary to

ascites. ascites.

ContraindicationsContraindications

Uncooperative patient Uncooperative patient

Skin infection at the proposed puncture Skin infection at the proposed puncture site site

Pregnancy Pregnancy

Severe bowel distension Severe bowel distension

Coagulopathy (opinion divided - some feel Coagulopathy (opinion divided - some feel only precluded where there is clinically only precluded where there is clinically evident fibrinolysis or DIC) evident fibrinolysis or DIC)

EquipmentEquipmentThe equipment required can be found in a disposable The equipment required can be found in a disposable paracentesis/thoracentesis kit. It includes the following: paracentesis/thoracentesis kit. It includes the following: – Antiseptic swab sticksAntiseptic swab sticks– Fenestrated drapeFenestrated drape– Lidocaine 1%, 5-mL ampuleLidocaine 1%, 5-mL ampule– Syringe, 10 mLSyringe, 10 mL– Injection needles, 22 gauge (ga), 2Injection needles, 22 gauge (ga), 2– Injection needle, 25 gaInjection needle, 25 ga– Scalpel, No. 11 bladeScalpel, No. 11 blade– Catheter, 8F, over 18 ga x 7 1/2" needle with 3-way stopcock, self-sealing valve, Catheter, 8F, over 18 ga x 7 1/2" needle with 3-way stopcock, self-sealing valve,

and a 5-mL Luer-Lock syringeand a 5-mL Luer-Lock syringe– Syringe, 60 mLSyringe, 60 mL– Introducer needle, 20 gaIntroducer needle, 20 ga– Tubing set with roller clampTubing set with roller clamp– Drainage bag or vacuum containerDrainage bag or vacuum container– Specimen vials or collection bottles, 3Specimen vials or collection bottles, 3– Gauze, 4 X 4 inchGauze, 4 X 4 inch– Adhesive dressingAdhesive dressing

PositioningPositioning

The two recommended areas of abdominal wall entry for The two recommended areas of abdominal wall entry for paracentesis are as follows (see photo): paracentesis are as follows (see photo): – Two centimeters below the umbilicus in the midline (through the Two centimeters below the umbilicus in the midline (through the

linea alba)linea alba)– Five centimeters superior and medial to the anterior superior Five centimeters superior and medial to the anterior superior

iliac spines on either sideiliac spines on either side

The authors recommend the routine use of The authors recommend the routine use of ultrasonography to verify the presence of a fluid pocket ultrasonography to verify the presence of a fluid pocket under the selected entry site in order to increase the rate under the selected entry site in order to increase the rate of success.6 The ultrasound also helps the practitioner of success.6 The ultrasound also helps the practitioner avoid a distended urinary bladder or small bowel avoid a distended urinary bladder or small bowel adhesions below the selected entry point. To minimize adhesions below the selected entry point. To minimize complications, avoid areas of prominent veins (caput complications, avoid areas of prominent veins (caput medusa), infected skin, or scar tissue. medusa), infected skin, or scar tissue.

TechniqueTechnique

Explain the procedure, benefits, risks, Explain the procedure, benefits, risks, complications, and alternative options to complications, and alternative options to the patient or the patient's representative the patient or the patient's representative and obtain signed informed consent.and obtain signed informed consent.Empty the patient's bladder, either Empty the patient's bladder, either voluntarily or with a Foley catheter.voluntarily or with a Foley catheter.Position the patient and prepare the skin Position the patient and prepare the skin around the entry site with an antiseptic around the entry site with an antiseptic solution.solution.

TechniqueTechnique

Explain the procedure, Explain the procedure, benefits, risks, complications, benefits, risks, complications, and alternative options to the and alternative options to the patient or the patient's patient or the patient's representative and obtain representative and obtain signed informed consent.signed informed consent.Empty the patient's bladder, Empty the patient's bladder, either voluntarily or with a either voluntarily or with a Foley catheter.Foley catheter.Position the patient and Position the patient and prepare the skin around the prepare the skin around the entry site with an antiseptic entry site with an antiseptic solution.solution.

TechniqueTechniqueApply a sterile fenestrated drape Apply a sterile fenestrated drape to create a sterile field. to create a sterile field. Use the 5-mL syringe and the 25-Use the 5-mL syringe and the 25-ga needle to raise a small ga needle to raise a small lidocaine skin wheal around the lidocaine skin wheal around the skin entry site. skin entry site. Switch to the longer 20-ga needle Switch to the longer 20-ga needle and administer 4-5 mL of and administer 4-5 mL of lidocaine along the catheter lidocaine along the catheter insertion tract. Make sure to insertion tract. Make sure to anesthetize all the way down to anesthetize all the way down to the peritoneum. The authors the peritoneum. The authors recommend alternating injection recommend alternating injection and intermittent aspiration down and intermittent aspiration down the tract until ascitic fluid is the tract until ascitic fluid is noticed in the syringe. Note the noticed in the syringe. Note the depth at which the peritoneum is depth at which the peritoneum is entered. In obese patients, entered. In obese patients, reaching the peritoneum may reaching the peritoneum may involve passing through a involve passing through a significant amount of adipose significant amount of adipose tissue. tissue.

TechniqueTechnique

Use the No. 11 scalpel blade Use the No. 11 scalpel blade to make a small nick in the to make a small nick in the skin to allow an easier skin to allow an easier catheter passage. catheter passage. Insert the needle directly Insert the needle directly perpendicular to the selected perpendicular to the selected skin entry point. Slow skin entry point. Slow insertion in increments of 5 insertion in increments of 5 mm is preferred to minimize mm is preferred to minimize the risk of inadvertent the risk of inadvertent vascular entry or puncture of vascular entry or puncture of the small bowel. the small bowel.

TechniqueTechnique

Continuously apply negative pressure to the syringe as the needle is Continuously apply negative pressure to the syringe as the needle is advanced. Upon entry to the peritoneal cavity, loss of resistance is advanced. Upon entry to the peritoneal cavity, loss of resistance is felt and ascitic fluid can be seen filling the syringe. At this point, felt and ascitic fluid can be seen filling the syringe. At this point, advance the device 2-5 mm into the peritoneal cavity to prevent advance the device 2-5 mm into the peritoneal cavity to prevent misplacement during catheter advancement. In general, avoid misplacement during catheter advancement. In general, avoid advancing the needle deeper than the safety mark that is present on advancing the needle deeper than the safety mark that is present on most commercially available catheters or deeper than 1 cm beyond most commercially available catheters or deeper than 1 cm beyond the depth at which ascitic fluid was noticed in the lidocaine syringe. the depth at which ascitic fluid was noticed in the lidocaine syringe.

TechniqueTechniqueUse one hand to firmly anchor the Use one hand to firmly anchor the needle and syringe securely in place to needle and syringe securely in place to prevent the needle from entering prevent the needle from entering further into the peritoneal cavity. further into the peritoneal cavity. Use the other hand to hold the Use the other hand to hold the stopcock and catheter and advance stopcock and catheter and advance the catheter over the needle and into the catheter over the needle and into the peritoneal cavity all the way to the the peritoneal cavity all the way to the skin. If any resistance is noticed, the skin. If any resistance is noticed, the catheter was probably misplaced into catheter was probably misplaced into the subcutaneous tissue. If this is the the subcutaneous tissue. If this is the case, withdraw the device completely case, withdraw the device completely and reattempt insertion. When and reattempt insertion. When withdrawing the device, always remove withdrawing the device, always remove the needle and catheter together as a the needle and catheter together as a unit in order to prevent the bevel from unit in order to prevent the bevel from cutting the catheter. cutting the catheter.

TechniqueTechnique

While holding the stopcock, While holding the stopcock, pull the needle out. The self-pull the needle out. The self-sealing valve prevents fluid sealing valve prevents fluid leak.leak.Attach the 60-mL syringe to Attach the 60-mL syringe to the 3-way stopcock and the 3-way stopcock and aspirate to obtain ascitic fluid aspirate to obtain ascitic fluid and distribute it to the and distribute it to the specimen vials. Use the 3-specimen vials. Use the 3-way valve, as needed, to way valve, as needed, to control fluid flow and prevent control fluid flow and prevent leakage when no syringe or leakage when no syringe or tubing is attached. tubing is attached.

TechniqueTechnique

Connect one end of Connect one end of the fluid collection the fluid collection tubing to the stopcock tubing to the stopcock and the other end to and the other end to a vacuum bottle or a a vacuum bottle or a drainage bag. drainage bag.

TechniqueTechnique

The catheter can become The catheter can become occluded by a loop of bowel or occluded by a loop of bowel or omentum. If the flow stops, kink or omentum. If the flow stops, kink or clap the tubing to avert loss of clap the tubing to avert loss of suction, then break the seal and suction, then break the seal and manipulate the catheter slightly, manipulate the catheter slightly, then reconnect and see if flow then reconnect and see if flow resumes. Rotating the catheter resumes. Rotating the catheter about the long axis can sometimes about the long axis can sometimes reinstitute flow in models with side reinstitute flow in models with side ports.ports.Remove the catheter after the Remove the catheter after the desired amount of ascitic fluid has desired amount of ascitic fluid has been drained. Apply firm pressure, been drained. Apply firm pressure, as necessary, to stop bleeding, if as necessary, to stop bleeding, if present. Place a bandage over the present. Place a bandage over the skin puncture site. skin puncture site.

Liver biopsyLiver biopsy

By By

Arif MuttaqinArif Muttaqin

Liver BiopsyA liver biopsy is not a routine procedure, but is performed when it is necessary to determine the presence of liver disease and to look for malignancy, cysts, parasites, or other pathology. The actual procedure is only slightly uncomfortable. Most of the discomfort arises from being required to lie still for several hours afterwards to prevent bleeding from the biopsy site.

DefinitionDefinition

The liver is a pyramid-shaped organ that lies within the upper right The liver is a pyramid-shaped organ that lies within the upper right side of the abdomen. In a typical liver biopsy, a needle is inserted side of the abdomen. In a typical liver biopsy, a needle is inserted through the rib cage or abdominal wall and into the liver to obtain a through the rib cage or abdominal wall and into the liver to obtain a sample for examination.sample for examination.The procedure can also be performed by inserting a needle into the The procedure can also be performed by inserting a needle into the jugular vein in the neck and passing a catheter through the veins jugular vein in the neck and passing a catheter through the veins down to the liver to obtain the sample. down to the liver to obtain the sample. The biopsy helps diagnose a number of liver diseases. The biopsy The biopsy helps diagnose a number of liver diseases. The biopsy also helps in the assessment of the stage (early, advanced) of the also helps in the assessment of the stage (early, advanced) of the liver disease. This is especially important in hepatitis C infection.liver disease. This is especially important in hepatitis C infection.The biopsy also helps detect:The biopsy also helps detect:– cancercancer– infectionsinfections– the cause of an unexplained enlargement of the liverthe cause of an unexplained enlargement of the liver– abnormal liver enzymes that have been detected in blood testsabnormal liver enzymes that have been detected in blood tests

Core AssessmentCore Assessment

drug allergiesdrug allergies

medicationsmedications

bleeding problemsbleeding problems

pregnant pregnant


Lumbar puncture is a Lumbar puncture is a procedure that is often procedure that is often performed in the emergency performed in the emergency department to obtain department to obtain information about the information about the cerebrospinal fluid (CSF) cerebrospinal fluid (CSF) Although usually used for Although usually used for diagnostic purposes to rule out diagnostic purposes to rule out potential life-threatening potential life-threatening conditions such as bacterial conditions such as bacterial meningitis or subarachnoid meningitis or subarachnoid hemorrhage, lumbar puncture hemorrhage, lumbar puncture is also sometimes performed is also sometimes performed for therapeutic reasons, such for therapeutic reasons, such as the treatment of as the treatment of pseudotumor cerebri. pseudotumor cerebri.


CSF fluid analysis can also aid CSF fluid analysis can also aid in the diagnosis of various in the diagnosis of various other conditions, such as other conditions, such as demyelinating diseases and demyelinating diseases and carcinomatous meningitis. carcinomatous meningitis. Lumbar puncture should be Lumbar puncture should be performed only after a performed only after a neurological examination and neurological examination and should never delay potentially should never delay potentially lifesaving interventions such lifesaving interventions such as the administration of as the administration of antibiotics and steroids to antibiotics and steroids to patients with suspected patients with suspected bacterial meningitis. bacterial meningitis.

IndicationsIndications

Suspicion of meningitis Suspicion of meningitis

Suspicion of subarachnoid hemorrhage Suspicion of subarachnoid hemorrhage

Suspicion of central nervous system Suspicion of central nervous system diseases such as Guillain-Barré diseases such as Guillain-Barré syndrome3 and carcinomatous meningitissyndrome3 and carcinomatous meningitis

Therapeutic relief of pseudotumor cerebri Therapeutic relief of pseudotumor cerebri

ContraindicationsContraindicationsAbsolute contraindications to lumbar puncture are as follows:Absolute contraindications to lumbar puncture are as follows:

– Unequal pressures between the supratentorial and infratentorial compartments, usually inferred Unequal pressures between the supratentorial and infratentorial compartments, usually inferred by characteristic findings on the brain CT scan:by characteristic findings on the brain CT scan:

Midline shiftMidline shiftLoss of suprachiasmatic and basilar cisternsLoss of suprachiasmatic and basilar cisternsPosterior fossa massPosterior fossa massLoss of the superior cerebellar cisternLoss of the superior cerebellar cisternLoss of the quadrigeminal plate cisternLoss of the quadrigeminal plate cistern

– Infected skin over the needle entry siteInfected skin over the needle entry site

Relative contraindications to lumbar puncture are as follows:Relative contraindications to lumbar puncture are as follows:– Increased intracranial pressure (ICP)Increased intracranial pressure (ICP)– CoagulopathyCoagulopathy– Brain abscessBrain abscess

Indications for brain CT scan prior to lumbar puncture include the following:4 Indications for brain CT scan prior to lumbar puncture include the following:4 – Patients who are older than 60 yearsPatients who are older than 60 years– Patients who are immunocompromisedPatients who are immunocompromised– Patients with known CNS lesionsPatients with known CNS lesions– Patients who have had a seizure within 1 week of presentationPatients who have had a seizure within 1 week of presentation– Patients with abnormal level of consciousnessPatients with abnormal level of consciousness– Patients with focal findings on neurological examinationPatients with focal findings on neurological examination– Patients with papilledema seen on physical examination with clinical suspicion of elevated ICPPatients with papilledema seen on physical examination with clinical suspicion of elevated ICP

PreparePrepare

Lumbar puncture, commonly called a spinal tap, is the Lumbar puncture, commonly called a spinal tap, is the most common method. The test is usually done like this:most common method. The test is usually done like this:– The patient lies on his or her side, with knees pulled up toward The patient lies on his or her side, with knees pulled up toward

the chest, and chin tucked downward. Sometimes the test is the chest, and chin tucked downward. Sometimes the test is done with the person sitting up, but bent forward. done with the person sitting up, but bent forward.

– After the back is cleaned, the health care provider will inject a After the back is cleaned, the health care provider will inject a local numbing medicine (anesthetic) into the lower spine. local numbing medicine (anesthetic) into the lower spine.

– A spinal needle is inserted, usually into the lower back area. A spinal needle is inserted, usually into the lower back area. – Once the needle is properly positioned, CSF pressure is Once the needle is properly positioned, CSF pressure is

measured and a sample is collected. measured and a sample is collected. – The needle is removed, the area is cleaned, and a bandage is The needle is removed, the area is cleaned, and a bandage is

placed over the needle site. The person is often asked to lie placed over the needle site. The person is often asked to lie down for a short time after the test. down for a short time after the test.

PreparePrepareOccasionally, special x-rays are used to help guide the needle into the Occasionally, special x-rays are used to help guide the needle into the proper position. This is called fluoroscopy.proper position. This is called fluoroscopy.Lumbar puncture with fluid collection may also be part of other procedures, Lumbar puncture with fluid collection may also be part of other procedures, particularly a myelogram (x-ray or CT scan after dye has been inserted into particularly a myelogram (x-ray or CT scan after dye has been inserted into the CSF).the CSF).Alternative methods of CSF collection are rarely used, but may be Alternative methods of CSF collection are rarely used, but may be necessary if the person has a back deformity or an infection.necessary if the person has a back deformity or an infection.Cisternal puncture uses a needle placed below the occipital bone (back of Cisternal puncture uses a needle placed below the occipital bone (back of the skull). It can be dangerous because it is so close to the brain stem. It is the skull). It can be dangerous because it is so close to the brain stem. It is always done with fluoroscopy.always done with fluoroscopy.Ventricular puncture is even more rare, but may be recommended in people Ventricular puncture is even more rare, but may be recommended in people with possible brain herniation. This test is usually done in the operating with possible brain herniation. This test is usually done in the operating room. A hole is drilled in the skull, and a needle is inserted directly into one room. A hole is drilled in the skull, and a needle is inserted directly into one of brain's ventricles.of brain's ventricles.CSF may also be collected from a tube that's already placed in the fluid, CSF may also be collected from a tube that's already placed in the fluid, such as a shunt or a venitricular drain. These sorts of tubes are usually such as a shunt or a venitricular drain. These sorts of tubes are usually placed in the intensive care unit. placed in the intensive care unit.

Prepare for the TestPrepare for the Test

The patient (or guardian) must give the The patient (or guardian) must give the health care team permission to do the test.health care team permission to do the test.

Afterward, you should plan to rest for Afterward, you should plan to rest for several hours, even if you feel fine. You several hours, even if you feel fine. You won't be required to lie flat on your back won't be required to lie flat on your back the entire time, but rest is advised to the entire time, but rest is advised to prevent additional leakage of CSF around prevent additional leakage of CSF around the site of the puncture.the site of the puncture.

RisksRisks

Risks of lumbar puncture include:Risks of lumbar puncture include:– Bleeding into the spinal canal Bleeding into the spinal canal – Discomfort during the test Discomfort during the test – Headache after the test Headache after the test – Hypersensitivity (allergic) reaction to the anesthetic Hypersensitivity (allergic) reaction to the anesthetic – Infection introduced by the needle going through the skin Infection introduced by the needle going through the skin – There is an increased risk of bleeding in people who take blood There is an increased risk of bleeding in people who take blood

thinners.thinners.– Brain herniation may occur if this test is done on a person with a mass Brain herniation may occur if this test is done on a person with a mass

in the brain (such as a tumor or abscess). This can result in brain in the brain (such as a tumor or abscess). This can result in brain damage or death. This test is not done if an exam or test reveals signs damage or death. This test is not done if an exam or test reveals signs of a brain mass.of a brain mass.

– Damage to the nerves in the spinal cord may occur, particularly if the Damage to the nerves in the spinal cord may occur, particularly if the person moves during the test.person moves during the test.

– Cisternal puncture or ventricular puncture carry additional risks of brain Cisternal puncture or ventricular puncture carry additional risks of brain or spinal cord damage and bleeding within the brain.or spinal cord damage and bleeding within the brain.

Instructions for PatientsInstructions for Patients

Basic InstructionsBasic Instructions – Please arrange for a ride home after your lumbar puncture. Please arrange for a ride home after your lumbar puncture. – Drink extra fluids the day before Drink extra fluids the day before – No solid foods from midnight on, if lumbar puncture is scheduled for the No solid foods from midnight on, if lumbar puncture is scheduled for the

morning. morning. – Drink extra fluids (no caffeine) up to 2 hours before exam. Drink extra fluids (no caffeine) up to 2 hours before exam. – 2 hours before exam – NPO (If medications needed, take only with 2 hours before exam – NPO (If medications needed, take only with

swallow of water.) swallow of water.) – Please arrive 45 minutes before scheduled lumbar puncture Please arrive 45 minutes before scheduled lumbar puncture

appointment. Go to theappointment. Go to theLobby Registration office first then report to the 2nd floor Outpatient Lobby Registration office first then report to the 2nd floor Outpatient Department. Department.

– Plan on 2 to 3 hours from arrival to discharge. Plan on 2 to 3 hours from arrival to discharge. – On the ride home, the back of the seat should be in the full reclining On the ride home, the back of the seat should be in the full reclining

position ratherposition ratherthan straight up. It is important to lie as flat as possible to help prevent a than straight up. It is important to lie as flat as possible to help prevent a bad headache. bad headache.

EquipmentEquipment

Spinal or lumbar puncture tray (including the items listed below)Spinal or lumbar puncture tray (including the items listed below)Sterile glovesSterile glovesAntiseptic solution with skin swabsAntiseptic solution with skin swabsSterile drapeSterile drapeLidocaine 1% without epinephrineLidocaine 1% without epinephrineSyringe, 3 mLSyringe, 3 mLNeedles, 20 and 25 gauge (ga)Needles, 20 and 25 gauge (ga)Spinal needles, 20 and 22 gaSpinal needles, 20 and 22 gaThree-way stopcockThree-way stopcockManometerManometerFour plastic test tubes, numbered 1-4, with capsFour plastic test tubes, numbered 1-4, with capsSterile dressingSterile dressingOptional: Syringe, 10 mLOptional: Syringe, 10 mL

Lumbar puncture lateral recumbent position.


Position the patient Position the patient in the lateral in the lateral recumbent position recumbent position with hips, knees, with hips, knees, and chin flexed and chin flexed toward the chest in toward the chest in order to open the order to open the interlaminar spaces. interlaminar spaces. A pillow can be used A pillow can be used to support the head. to support the head.


The sitting position may The sitting position may be a helpful alternative be a helpful alternative position, especially in position, especially in obese patients (easier obese patients (easier to confirm the midline). to confirm the midline). In order to open the In order to open the interlaminar spaces, the interlaminar spaces, the patient should lean patient should lean forward and be forward and be supported by a Mayo supported by a Mayo stand with a pillow on it, stand with a pillow on it, by hunching over the by hunching over the back of a stool, or by back of a stool, or by another person.another person.

Lumbar puncture sitting position.

TechniqueTechniqueExplain the procedure, benefits, Explain the procedure, benefits, risks, complications, and alternative risks, complications, and alternative options to the patient or the patient's options to the patient or the patient's representative and obtain a signed representative and obtain a signed informed consent.informed consent.Wearing nonsterile gloves, locate Wearing nonsterile gloves, locate the L3-L4 interspace by palpating the L3-L4 interspace by palpating the right and left posterior superior the right and left posterior superior iliac crests and moving the fingers iliac crests and moving the fingers medially toward the spine. Palpate medially toward the spine. Palpate that interspace (L3-L4) as well as that interspace (L3-L4) as well as one above (L2-L3) and one below one above (L2-L3) and one below (L4-L5) to find the widest space. (L4-L5) to find the widest space. Mark the entry site with a thumbnail Mark the entry site with a thumbnail or a marker. To help open the or a marker. To help open the interlaminar spaces, the patient can interlaminar spaces, the patient can be asked to practice pushing the be asked to practice pushing the entry site area out toward the entry site area out toward the practitioner.practitioner.

L3-L4 interspace palpation.

TechniqueTechnique

Open the spinal tray, Open the spinal tray, change to sterile change to sterile gloves, and prepare the gloves, and prepare the equipment. Open the equipment. Open the numbered plastic tubes numbered plastic tubes and place them upright, and place them upright, assemble the stopcock assemble the stopcock on the manometer, and on the manometer, and draw the lidocaine into draw the lidocaine into the 10-mL syringe. the 10-mL syringe.

TechniqueTechnique

Use the skin swabs and antiseptic solution to clean Use the skin swabs and antiseptic solution to clean the skin in a circular fashion starting at the L3-L4 the skin in a circular fashion starting at the L3-L4 interspace and moving outward to include at least interspace and moving outward to include at least 1 interspace above and below. Just before 1 interspace above and below. Just before applying the skin swabs, warn the patient that the applying the skin swabs, warn the patient that the solution is very cold, since this can be unnerving to solution is very cold, since this can be unnerving to the patient. the patient. Place a sterile drape below the patient and a Place a sterile drape below the patient and a fenestrated drape on the patient. Most spinal trays fenestrated drape on the patient. Most spinal trays contain fenestrated drapes with an adhesive tape contain fenestrated drapes with an adhesive tape that keeps the drape in place. that keeps the drape in place.

TechniqueTechnique

Use the 10-mL syringe to administer local anesthesia. Raise a Use the 10-mL syringe to administer local anesthesia. Raise a skin wheal using the 25-ga needle and then switch to the longer skin wheal using the 25-ga needle and then switch to the longer 20-ga needle to anesthetize the deeper tissue. Insert the needle 20-ga needle to anesthetize the deeper tissue. Insert the needle all the way to the hub, aspirate to confirm that the needle is not in all the way to the hub, aspirate to confirm that the needle is not in a blood vessel, and then inject a small amount as the needle is a blood vessel, and then inject a small amount as the needle is withdrawn a few centimeters. Continue this process above, withdrawn a few centimeters. Continue this process above, below, and to the sides very slightly (using the same puncture below, and to the sides very slightly (using the same puncture site).site).

This process anesthetizes the entire immediate area so that, if This process anesthetizes the entire immediate area so that, if redirection of the spinal needle is necessary, the area will still be redirection of the spinal needle is necessary, the area will still be anesthetized. For this reason, a 10-mL syringe may be more anesthetized. For this reason, a 10-mL syringe may be more beneficial than the usual 3-mL syringe supplied with the standard beneficial than the usual 3-mL syringe supplied with the standard lumbar puncture kit. The 20-ga needle can also be used as a lumbar puncture kit. The 20-ga needle can also be used as a guide for the general direction of the spinal needle. In other guide for the general direction of the spinal needle. In other words, the best direction in which to aim the spinal needle can be words, the best direction in which to aim the spinal needle can be confirmed if the 20-ga needle encounters bone in one direction confirmed if the 20-ga needle encounters bone in one direction but not in another. but not in another.

TechniqueTechnique

Stabilize the needle (20 or 22 ga) with the index fingers and Stabilize the needle (20 or 22 ga) with the index fingers and advance it through the skin wheal using the thumbs. Orient the advance it through the skin wheal using the thumbs. Orient the bevel parallel to the longitudinal dural fibers to increase the chances bevel parallel to the longitudinal dural fibers to increase the chances of the needle separating the fibers rather than cutting them (bevel of the needle separating the fibers rather than cutting them (bevel facing up in the lateral recumbent position and facing to either side facing up in the lateral recumbent position and facing to either side in the sitting position). in the sitting position). Insert the needle at a slightly cephalad angle toward the umbilicus. Insert the needle at a slightly cephalad angle toward the umbilicus. Advance the needle slowly but smoothly. Occasionally, the Advance the needle slowly but smoothly. Occasionally, the practitioner feels a characteristic "pop" when the needle penetrates practitioner feels a characteristic "pop" when the needle penetrates the dura. Otherwise, the stylet should be withdrawn after the dura. Otherwise, the stylet should be withdrawn after approximately 4-5 cm and observed for fluid return. If no fluid approximately 4-5 cm and observed for fluid return. If no fluid returns, replace the stylet, advance or withdraw the needle a few returns, replace the stylet, advance or withdraw the needle a few millimeters, and recheck for fluid return. Continue this process until millimeters, and recheck for fluid return. Continue this process until fluid is successfully returned. fluid is successfully returned.

TechniqueTechnique

To measure the opening pressure, the patient must be in To measure the opening pressure, the patient must be in the lateral recumbent position. After fluid returns from the the lateral recumbent position. After fluid returns from the needle, attach the manometer through the stopcock and needle, attach the manometer through the stopcock and note the height of the fluid column. The patient's legs note the height of the fluid column. The patient's legs should be straightened when measuring open pressure should be straightened when measuring open pressure or a falsely elevated pressure will be obtained. or a falsely elevated pressure will be obtained. Collect at least 10 drops of CSF in each of the 4 plastic Collect at least 10 drops of CSF in each of the 4 plastic tubes, starting with tube #1. The CSF that is in the tubes, starting with tube #1. The CSF that is in the manometer should be used (if possible) for tube #1.manometer should be used (if possible) for tube #1.Replace the stylet and remove the needle. Clean off the Replace the stylet and remove the needle. Clean off the skin preparatory solution. Apply a sterile dressing and skin preparatory solution. Apply a sterile dressing and place the patient in the supine position. place the patient in the supine position.

PearlsPearls

If the patient is dehydrated, a falsely negative dry tap may be If the patient is dehydrated, a falsely negative dry tap may be obtained as a result of very low CSF volume and pressure. If this is obtained as a result of very low CSF volume and pressure. If this is suspected, attempt to rehydrate the patient prior to the procedure.suspected, attempt to rehydrate the patient prior to the procedure.If the procedure is performed in the sitting position and an opening If the procedure is performed in the sitting position and an opening pressure is required (eg, pseudotumor cerebri), replace the stylet pressure is required (eg, pseudotumor cerebri), replace the stylet and have an assistant help the patient into the left lateral recumbent and have an assistant help the patient into the left lateral recumbent position. No data suggest increased risk of spinal headache or position. No data suggest increased risk of spinal headache or transection of the spinal nerves with position change. Take care not transection of the spinal nerves with position change. Take care not to change the orientation of the spinal needle during this maneuver.to change the orientation of the spinal needle during this maneuver.The amount of lidocaine provided in most kits is often inadequate. The amount of lidocaine provided in most kits is often inadequate. The authors recommend supplementing the kit with a 10-mL syringe The authors recommend supplementing the kit with a 10-mL syringe and a bottle of 1% lidocaine. Make sure not to exceed the maximal and a bottle of 1% lidocaine. Make sure not to exceed the maximal recommend dose of 4.5 mg/kg of lidocaine. A smaller (27 ga, 1 1/4") recommend dose of 4.5 mg/kg of lidocaine. A smaller (27 ga, 1 1/4") needle may be used for infiltration. Smaller needles are shown to be needle may be used for infiltration. Smaller needles are shown to be associated with less pain during local anesthesia.associated with less pain during local anesthesia.

PearlsPearlsIf the CSF flow is too slow, ask the patient to cough or bear down as in the If the CSF flow is too slow, ask the patient to cough or bear down as in the Valsalva maneuver, or ask an assistant to intermittently press on the Valsalva maneuver, or ask an assistant to intermittently press on the patient’s abdomen to increase the flow. Alternatively, the needle can be patient’s abdomen to increase the flow. Alternatively, the needle can be rotated 90 degrees such that the bevel faces cephalad.rotated 90 degrees such that the bevel faces cephalad.Never delay intravenous antibiotics for a lumbar puncture or a pre-lumbar Never delay intravenous antibiotics for a lumbar puncture or a pre-lumbar puncture CT scan. Meningitis can usually be inferred from the cell count, puncture CT scan. Meningitis can usually be inferred from the cell count, antigen detection, or both.antigen detection, or both.The smaller the needle used for the lumbar puncture, the lower the risk The smaller the needle used for the lumbar puncture, the lower the risk of the patient developing a post–lumbar puncture headache. Data suggest a of the patient developing a post–lumbar puncture headache. Data suggest a inverse linear relationship to gauge, and the authors recommend using a inverse linear relationship to gauge, and the authors recommend using a 22-ga needle, regardless of what size needle is supplied with the kit.5 22-ga needle, regardless of what size needle is supplied with the kit.5 The use of atraumatic needles has been shown to significantly reduce the The use of atraumatic needles has been shown to significantly reduce the incidence of post – lumbar puncture headache (3%) when compared to incidence of post – lumbar puncture headache (3%) when compared to standard spinal needles (approximately 30%).6,7 Obtaining pressures can standard spinal needles (approximately 30%).6,7 Obtaining pressures can be more difficult with these needles.be more difficult with these needles.Prophylactic bed rest following lumbar puncture has not been shown to be Prophylactic bed rest following lumbar puncture has not been shown to be of benefit and should not be recommended.8,9,10 of benefit and should not be recommended.8,9,10

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